The quality of surgical care varies widely in the United States, and identifying appropriate quality indicators is essential. Our current paradigm of quality assessment in surgery primarily focuses on clinical outcomes, such as complication rates, mortality, and readmission. This approach effectively captures perioperative safety and technical performance, but overlooks the patient perspective. Patient-reported outcomes (PROs), such as self-reported health status, function, and quality of life, could offer a more complete assessment of quality. However, little is known about their potential as a quality metric. This proposal will explore the determinants of variation in PROs at the hospital and surgeon level, their advantages and limitations as an indicator of quality, and their value and application for patients considering surgery. In addition to the innovative research plan, this proposal will provide the career development candidate (Dr. Jennifer Waljee) with a rich methodological training and mentorship experience. The research proposal focuses specifically on the variation of PROs at the population level for four surgical conditions: bariatric, urologic, wrist, and spine surgery. These conditions were chosen from the regional surgical collaborative quality improvement programs led by the University of Michigan at the Center for Healthcare Outcomes and Policy with funding from the Blue Cross and Blue Shield of Michigan/Blue Care Network. Each of these collaborative programs gathers clinical and patient-reported data from patients undergoing surgery from each participating hospital, and is a unique clinical laboratory to study PROs across hospitals and surgeons on a population-based level. The proposal's research aims include (1) examining the variation in PROs across hospitals and surgeons, and the patient, surgeon, and hospital-level factors that drive this variation; (2) the extent to which PROs are independent measures of quality compared with clinical outcomes; and (3) the way in which patients might use PROs in conjunction with clinical outcomes as measures of hospital and surgeon performance. This project, the multidisciplinary mentorship team, and the research environment are ideally suited to address the career goals and educational needs of Dr. Waljee. Her prior research experience examining PROs following surgery has prepared her to conduct the work outlined in this proposal. However, to achieve her career goal of improving quality assessment in surgery by integrating patient reported outcomes as performance measures, she will need additional training. Her educational goals, including obtaining expertise in survey research, advanced statistical methods for comparing provider performance, and approaches to healthcare organization and policy, are feasible with the grant's educational plan and highly accomplished mentorship team. This proposal includes graduate-level courses in each educational component as well as interactive research seminars and one-on-one mentorship through project-based learning. In summary, this research project, mentorship team, and educational plan will lay the groundwork for Dr. Waljee to perform ongoing and innovative research to improve quality assessment in surgery, and mature as an independent surgeon scientist.